Transcript Optimizing Patient Outcomes in Non-Hodgkin Lymphoma

Optimizing Patient Outcomes in
Non-Hodgkin Lymphoma: An
Update for Oncology Nurses
Barbara Barnes Rogers, CRNP, MN, AOCN, ANP-BC
Adult Hematology-Oncology Nurse Practitioner
Fox Chase Cancer Center
Disclosure of Conflicts of Interest
Barbara B. Rogers has an affiliation with
Celgene (Advisory Board) and Allos,
Cephalon, Seattle Genetics, and
Millennium (Speaker’s Bureaus).
Learning Objectives
After completing this activity, the participant should
be better able to:
• Discuss the classification, presentation, and
diagnosis of NHL
• Explain the prognosis of NHL using established
prognostic models
• Identify the different classes and mechanisms of
therapeutic agents for treating NHL
• Recognize the signs and symptoms of side effects
and complications associated with chemotherapy
• Manage chemotherapy side effects and
complications in patients with NHL
Non-Hodgkin Lymphoma
• A heterogeneous group of lymphoid
tumors that have distinct clinical and
biologic behaviors
• Accurate diagnosis of specific NHL
subtype important to understand
management
• Biological and clinical heterogeneity can
be noted within each subtype
Incidence of NHL
• Incidence rising:
– Faster than that of all other malignancies except lung cancer in women,
melanoma and prostate cancer
– Age-adjusted incidence in US increased from 11.1 per 100,000 in 1975 to
19.8 per 100,000 in 2008
• Reason for rising incidence:
– NHL in patients with acquired immunodeficiency syndrome (AIDS)
– Improvements in diagnosis
– Other reasons (most likely primary cause)
• Estimated new cases in the US in 2011 is 66,360
• Race:
– 30% higher in whites than blacks
– Blacks > whites age less than 50
– Whites > blacks age over 55
Greer J, Williams M. Wintrobe’s Clinical Hematology (12th Ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009.
American Cancer Society: Cancer facts and figures 2011.
Epidemiology
• Variable world-wide distribution
• More common in males than females
• Represent ~10% of all childhood cancers in
developed countries
• More common in adults than children
• Steady increase in incidence from childhood
through age 80 years
• Seventh most common malignancy in US
• Represent 4% of all cancers
Risk Factors
– Abnormality of immune function:
• HIV infection
• Iatrogenic immune suppression
• Autoimmune diseases
• Congenital immune deficiencies
• Wiskott-Aldrich
• X-linked lymphoproliferative disorder
– Infectious agents:
• Gamma herpes viruses
• Epstein-Barr virus - associated with African Burkitt lymphoma, AIDS-related
DLBCL, NK/T-cell nasal type lymphoma
• Kaposi’s sarcoma-associated herpes virus (human herpes virus 8) - linked to
primary effusion lymphomas and multicentric Castleman’s disease
• Human T-lymphotropic virus I (HTLVI) - adult T-cell leukemia/lymphoma
• Helicobacter pylori - gastric malt
• Hepatitis C virus - spenic marginal zone lymphoma; other B-cell lymphomas
• Campylobacter jejuni - immunoproliferative small intestinal disease
• Borrelia burgdorferi - primary cutaneous B-cell lymphoma
• Chlamydia psittaci - ocular adnexal lymphoma
Greer J, Williams M. Wintrobe’s Clinical Hematology (12th Ed). Philadelphia: Wolters Kluwer/Lippincott Williams &
Wilkins, 2009.
Environmental Factors
Associated with NHL
– Environmental and occupational exposures
• Organic compounds (organophosphate insecticides)
• Drug exposure
–
–
–
–
Phenytoin
Carbamazepine
Methotrexate
TNF-α inhibitors - etanercept, infliximab, adalimumab
• Toxic chemical exposure
Greer J, Williams M. Wintrobe’s Clinical Hematology (12th Ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins,
2009.
Clinical Features of NHL
• Painless adenopathy - more common in cervical,
axilla, or groin
• B symptoms - fevers, night sweats, weight loss
• Extranodal disease can be detected in up to 40% of
patients
–
–
–
–
GI tract most common site
Skin
CNS involvement
Ocular
• Significant cytopenias rare
• Hepatosplenomegaly - common feature of advanced
disease manifested by upper abdominal pain
Where Do B-Cell Lymphomas
Originate?
Jaffe E, et al. Blood. 2008;112:4384-4399.
Classifications of NHL
• B-cell vs T-cell
– B-cell NHL - 88% of all NHLs
– T-cell NHL - 12% of all NHLs
• Indolent vs Aggressive
• WHO classification includes:
– Immunophenotypic
– Molecular
– Genetic
– Clinical elements
Diagnostic Work-Up
History and Physical
CBC with diff/plts
Viral Testing: HIV, HTLV-1, Hepatitis
Metabolic Panel with LDH
B2 microglobulin
CXR
CT of neck, chest, abdomen, pelvis
PET/CT
Biopsy with flow cytometry and cytogenetics
Bone marrow aspirate and biopsy
Lumbar puncture with cytology, if indicated
GI endoscopy in those with GI symptoms
Indications for Lumbar Puncture
• Small non-cleaved cell NHL
• Lymphoblastic lymphomas
• NHL of certain sites:
– Nasopharynx
– Epidural space
– Testes
– Large cell with marrow involvement
– HIV +
Greer J, Williams M. Wintrobe’s Clinical Hematology (12th Ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009.
Subtypes of NHL
Burkitt
(2.5%)
Mantle cell
(6%)
Follicular
(25%)
Other subtypes
(9%)
Small lymphocytic
lymphoma/CLL
(7%)
T and NK cell
(12%)
Diffuse large B cell
(30%)
MALT-type
marginal-zone B cell (7.5%)
Nodal-type
marginal-zone B cell
(< 2%)
Lymphoplasmacytic
(< 2%)
Lichtman MA. Williams Hematology. (7th Ed). New York, NY: McGraw Hill, 2006;1408.
Antigen Expression Associated
with B-Cell NHL
Bone Marrow
Periphery (Spleen, Lymph Node)
Memory B
Pro-B
Pre-B
Immature B Mature B
Mature B
GC B
Plasmablast
Plasma Cell
CD19
+
+
+
+
+
+
+
–
CD10
+
+
+/–
–
–
+
–
–
CD20
–
–
–/+
+
+
++
+
–
CD38
++
++
+
+
+
++
+
++
CD22
–
–
+
+
+
+
+
?
–
–
–
–
–
CD52
CD80
–
ALL
ALL = acute lymphoblastic leukemia
CLL = chronic lymphocytic leukemia
Activated B-cells
CLL, –
PLL Burkitt’s, FL, DLBCL, HCL
FL = follicular lymphoma
DLBCL = diffuse large B-cell lymphoma
PLL = prolymphocytic leukemia
WM
MM
HCL = hairy cell leukemia
MM = multiple myeloma
WM = Waldenström’s macroglobulinemia
Jaffe ES, et al, eds. World Health Organization Classification of Tumours. 2001. Hale G, et al. Tissue Antigens. 1990;35:118-127.
Freeman GJ, et al. J Immunol. 1989;143:2714-2722.
Molecular Indices in Lymphocytic Malignancies
Lymphoma Subtype Morphology
Immunophenotyping
Favorable = f
Unfavorable = u
Common
Cytogenetic
Abnormalities
Molecular Testing
Diffuse large
B-cell (DLBCL)
Diffuse pattern with
distortion of the normal
architecture of the lymph
node or extranodal site
CD20+, CD45+, CD3-
t(14;18), t(3;v),
t(8;14)
Testing for bcl-2, bcl-1,
c-myc
All offer a survival advantage to the
lymphoma cells u
Follicular
lymphoma (FL)
Nodal lymphoma with a
follicular growth pattern
CD10+,CD20+, sIg+,
CD23+/-, CD22+, CD25+/-
t(14;18)(q32;q21) 85%
IgH re-arrangement with bcl-2
expression which leads to cellular
resistance to apoptosis u
Small lymphocytic
lymphoma/
chronic
lymphocytic
leukemia
Usually appear normal,
may be large, smudge
cells may be present, prolymphocytes are common
CD5+, CD20dim+, sIgdim+,
CD23+, CD22-, CD25-(+)
CD38+ u
Trisomy 12
t(11q;v) u
del(11q) u
del(17p) u
del(13q) f
Patients with variable region Ig
mutations have a more favorable
prognosis u
Mantle cell
lymphoma (MCL)
Cells populating the
mantle zone of the follicle
CD5+, CD20+, sIg+, CD22+,
CD45+
CD10-, CD23-, CD25Cyclin D1+
t(11;14)(q13;q32)
de-regulates cyclin D1
expression interfering
with cell cycle
regulation
IgH re-arrangement with bcl-1
(increased cell proliferation), and
bcl-6 expression (resistance to
apoptosis) u
Peripheral
T-cell lymphoma
(PTLC)
Peripheral T-cells and no
features of other subtypes
CD4+, CD7-, CD8-
Kurtin S. Oncology Nurse. 2008;1(5):1-2.
Clonal re-arrangements of the
receptor genes seen in noncancerous T-cell disease are
common
Differences Between Childhood and
Adult Non-Hodgkin Lymphomas
Children
Adults
Incidence
Rare
Common
Median Age
10-15y
55-70y
Presentation
Extranodal > nodal
Nodal > extranodal
Most common
histologic diagnoses
B cell: Burkitt, diffuse large
cell
T cell: Lymphoblastic; ALK+
anaplastic large cell
B cell: diffuse large cell
(DLBCL), small cleaved
(follicular center) cell
T cell: Peripheral T-cell
unspecified; anaplastic large
cell; angioimmunoblastic
Immunophenotype
50-70% B cell
85-90% B cell (US &
Europe)
Paraprotein
None
Rare (<5%)
Clinical course
Aggressive
Variable - often indolent
Curability
70-90%
<30% except 40-70% in
aggressive subtypes,
particularly DLBCL
Greer J, Williams M. Wintrobe’s Clinical Hematology (12th Ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009.
Indolent NHL
•
•
•
•
•
•
Long median survival
Slow but continuous decline in survival
Usually advanced stage at presentation
Respond to therapy but relapse
May transform to aggressive lymphoma
Rarely, can spontaneously regress
Indolent Lymphoma Subtypes
• Follicular lymphoma
• Small lymphocytic lymphoma
• Lymphoplasmacytic lymphoma
(Waldenström macroglobulinemia)
• Marginal zone lymphoma
• Splenic marginal zone lymphoma
• Primary cutaneous anaplastic large cell
lymphoma
• Mycosis fungoides (Sézary syndrome)
National Cancer Institute: Adult Non-Hodgkin Lymphoma Treatment (PDOR), cellular classification of adult NHL.
Aggressive Lymphomas
• Present acutely or sub-acutely with:
– A rapidly growing mass
– Systemic B symptoms:
• Fever
• Night sweats
• Weight loss
– Elevated serum LDH (lactate dehydrogenase)
– Elevated uric acid
• Examples:
–
–
–
–
–
Diffuse large B cell lymphoma
Burkitt lymphoma
Adult T cell leukemia/lymphoma
Precursor B and T lymphoblastic leukemia/lymphoma
Mantle cell lymphoma
Greer J, Williams M. Wintrobe’s Clinical Hematology (12th Ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009.
Peripheral T-cell Lymphoma Subtypes
ALCL = anaplastic large-cell lymphoma
ALK = anaplastic lymphoma kinase
PTCL = peripheral T-cell lymphoma.
O’Leary. Curr Opin Hematol. 2009;16:292.
International T-Cell Lymphoma Project. J Clin Oncol. 2008;26:4124.
de Leval. Hematology Am Soc Hematol Educ Program. 2008;272.
Ann Arbor Staging System
Stage
Description
I
Single lymph node region or single
extralymphatic organ or site
II
Two or more lymph node regions on the
same side of the diaphragm or single
exanodal site with adjacent nodes
III
Nodal regions on both sides of the
diaphragm or involving single extranodal
site with adjacent nodes, or spleen or both
IV
Diffuse or disseminated involvement of
one or more extralymphatic organs, bone
marrow, liver, brain involvement
A
No symptoms
B
Fevers, chills, night sweats, weight loss
E
Extranodal involvement
X
Bulky
S
Spleen involvement
Prognostic Indexes
IPI
AA-IPI
FLIPI
MIPI
PIT
Age >60 years
Performance
Status 2 or
more
Age >60y
Age
Age
Performance
Status
LDH above
normal
Stage III/IV
Performance
Status
Performance
Status
LDH above
normal
Stage III or IV
Hemoglobin
<12 g/L
LDH
LDH
Two or more
extranodal
sites
Number of
nodal areas >4
Leukocyte
count
BM
Involvement
Stage III or IV
LDH> normal
IPI = International Prognostic Index
AA-IPI = Age Adjusted IPI
FLIPI = Follicular Lymphoma IPI
MIPI = Mantle Cell IPI
PIT = Peripheral T cell NHL IPI
The International Non-Hodgkin’s Lymphoma Prognostic
Factor Project. N Engl Med. 1993;329:987-994.
Solal-Celigny, et al. Blood. 2004;104:1258-1265.
Gallamini A, et al. Blood. 2004;103:2474-2479.
Geisler C, et al. Blood. 2010;115:1530-1533.
Progression-Free Survival Based on IPI
Sehn L, et al. Blood. 2007;109:1857-1861.
Overall Survival of Patients with PTCL
Based on Prognostic Index for PTCL (PIT)
Group 1 Group 2 Group 3 Group 4 -
Gallamini A, et al. Blood. 2004;103:2474-2479.
0 risk factors
1 risk factor
2 risk factors
3-4 risk factors
Treatment Related Issues
• Ability of patient to tolerate treatment
dependent on:
– Age
– Performance status
– Immunodeficiency from pre-lymphomatous
condition
• Higher mortality in elderly
– Increased treatment related toxicities
– Death from unrelated causes are increased
– Greater lymphoma related mortality
Management of Indolent Lymphoma:
Treatment Options
• Watchful waiting
• Local radiation for limited
stage disease
• Chemotherapy:
– Alkylating agent
– Nucleoside analog
– Combination chemotherapy
• Immunotherapy:
– Unconjugated monoclonal
antibody
– Radioimmunotherapy
– Interferons
– Interleukins
– Vaccines
• Combined modality
therapy:
– Chemotherapy and radiation
therapy
– Chemotherapy and
immunotherapy
• Transplantation:
– Autologous
– Allogeneic:
• Myeloablative
• Non-myeloablative
• Selective therapies:
– Antibiotics in selected
maltomas
– Splenectomy
Greer J, Williams M. Wintrobe’s Clinical Hematology (12th Ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009.
Management of Diffuse Large
B-Cell Lymphoma (DLBCL)
• Initial: R-CHOP =/- IFRT
– Management of aggressive (high Ki67) DLBCL
• Relapsed: +/- autologous transplant
–
–
–
–
–
–
RICE
R-DHAP
R-ESHAP
R-GemOx
R-MINE
R-GDP
NCCN. Non-Hodgkin’s Lymphoma. Version 2.2012.
Management of Follicular
Non-Hodgkin’s Lymphoma
Frontline:
Bendamustine/Rituximab
R-CHOP
R-CVP
Rituximab
R-Fludarabine
Clinical Trial
Relapsed:
Rituximab
Bendamustine/Rituximab
R-CHOP
R-CVP
Lenolidomide
Radioimmunotherapy
Clinical Trial
NCCN. Non-Hodgkin’s Lymphoma. Version 2.2012.
Management of
Peripheral T-Cell Lymphoma
Frontline:
CHOP
Hyper CVAD
Clinical Trial
Autologous Peripheral Stem Cell Transplant as consolidation
Recurrent/Refractory:
DHAP
ESHAP
GDP
ICE
Pralatrexate
Romidepsin
Brentuximab vedotin
Alemtuzumab
Cyclosporine
Bortezomib
Denileukin diftitox
Gemcitabine
Clinical Trial
Foss F, et al. Blood. 2011;117:6756-6767.
Role of Transplant in the
Management of NHL
• Outcomes dependent on:
– Disease State:
• Type of lymphoma
• Remission status - best outcome in patients in first CR or have
minimal disease before transplant
– Patients with disease that is responsive to therapy have 30-60%
salvage rate
– Patients with resistant relapse have 0-15% salvage rate
– Patient factors:
• Age
• Performance Status
– Source of stem cells
• Autologous
• Allogeneic - higher mortality rate
• No superior preparative regimen
Overall Survival in PTCL
The International PTCL and NK/T-Cell Lymphoma Study
PTCL Subtypes
5-Yr OS Rate (%)
ALK+
ALCL
ALK–
ALCL
PTCLNOS
AITL
NK/T-Cell
Lymphoma
ATLL
70
49
32
32
32
14
ATLL = adult T-cell leukemia/lymphoma; OS = overall survival.
International T-Cell Lymphoma Project, 2008.
Vose J, et al. J Clin Oncol. 2008;26:4124-4130.
Side Effects of Agents Used in the
Treatment of B-Cell LymphomasCHOP
Cyclophosphamide - hemorrhagic
cystitis, nausea and vomiting,
anorexia, stomatitis, diarrhea,
hepatotoxicity, neutropenia,
alopecia, sexual dysfunction,
SIADH, pulmonary toxicity.
Doxorubicin - neutropenia,
thrombocytopenia, cardiac toxicity,
nausea and vomiting, anorexia,
stomatitis, alopecia, radiation
recall, nail and skin changes, drug
extravasation, sexual dysfunction.
Vincristine - peripheral neuropathy,
constipation, alopecia, mild
neutropenia, mild thrombocytopenia,
impotence.
Prednisone - gastric irritation,
decreased carbohydrate metabolism,
hyperglycemia, edema, fluid and
electrolyte alterations,
immunosuppression, cushingoid
changes, cataracts, glaucoma, ocular
infections, behavioral changes, muscle
weakness.
Wilkes G, Barton-Burke M. Oncology Nursing Drug Handbook (2011 Ed). Sudbury, MA: Jones and Bartlett Publishers, 2011.
Side Effects of Agents Used in the
Management of NHL
Rituximab - infusion reactions,
tumor lysis, lymphopenia,
mucocutaneous reactions,
reactivation of hepatitis B, nausea
and vomiting, pruritus, myalgias.
Fludarabine - neutropenia,
thrombocytopenia, pulmonary
toxicity, nausea and vomiting,
diarrhea.
Bendamustine - neutropenia, anemia,
thrombocytopenia, infusion reaction,
tumor lysis, nausea and vomiting,
diarrhea, rash.
Lenalidomide - neutropenia,
thrombocytopenia, anemia, rash,
fatigue, light headedness, leg cramps,
diarrhea, constipation, nausea,
electrolyte imbalance, birth defects.
Wilkes G, Barton-Burke M. Oncology Nursing Drug Handbook (2011 Ed). Sudbury, MA: Jones and Bartlett Publishers, 2011.
Side Effects of Agents Used in the
Treatment of B-Cell
Lymphomas-Radioimmunotherapy
90Y
Ibritumomab tiuxetan (Zevalin) infusion reaction, neutropenia,
anemia, thrombocytopenia, nausea,
abdominal pain, headache,
secondary malignancies.
131I
tositumomab (Bexxar) - infusion
reaction, neutropenia, anemia,
thrombocytopenia, secondary
malignancies, thyroid dysfunction.
Wilkes G, Barton-Burke M. Oncology Nursing Drug Handbook (2011 Ed). Sudbury, MA: Jones and Bartlett Publishers, 2011.
Side Effects of Agents Used in the
Management of T-Cell NHL
Romidepsin - anemia, leukopenia,
neutropenia, thrombocytopenia,
infection, EKG changes, asthenia,
decreased appetite, headache, cough,
rigors, weight loss.
Pralatrexate - stomatitis,
thrombocytopenia, nausea, fatigue,
anemia, neutropenia, dyspnea,
hypokalemia, altered LFTs, abdominal
pain, leukopenia, febrile neutropenia,
sepsis, hypotension.
Brentuximab vedotin - peripheral
neuropathy, nausea, fatigue, pyrexia,
diarrhea, rash, constipation, neutropenia.
Alemtuzumab - anemia, neutropenia,
thrombocytopenia, fever, infection, viremia
(CMV, EBV), hypotension, rash, urticaria,
diarrhea, nausea, vomiting, myalgias,
insomnia, anxiety, bronchospasm,
dyspnea.
Denileukin Diftitox - fever, fatigue, rigors,
nausea, headache, edema, cough,
dyspnea, pruritus, rash, hypotension, back
pain, myalgia, chest pain, tachycardia,
hypoalbuminemia, asthenia, altered LFTs,
capillary leak syndrome, infusion reactions,
visual impairment.
Wilkes G, Barton-Burke M. Oncology Nursing Drug Handbook (2011 Ed). Sudbury, MA: Jones and Bartlett Publishers, 2011.
Management of Side Effects of Agents
Used in the Management of NHL
Toxicity
Interventions
Myelosuppression (neutropenia,
anemia, thrombocyopenia)
1. Assess baseline CBC
2. Assess CBC throughout therapy
3. Assess for signs/symptoms of
infection or bleeding
4. Teach patient the signs and
symptoms of infection or bleeding
and to report these immediately
5. Teach patient self-care measures
to minimize risk of infection and
bleeding
6. Transfuse as necessary
7. Discuss need for dose
modifications with
prescriber/physician
Wilkes G, Barton-Burke M. Oncology Nursing Drug Handbook (2011 Ed). Sudbury, MA: Jones and Bartlett Publishers, 2011.
Management of Side Effects of Agents
Used in the Management of NHL
Nausea and vomiting
1. Teach patient to take antiemetic as needed
2. Administer antiemetic prior to administration of
chemotherapy
3. Encourage patient to eat small, frequent meals
4. Teach dietary modifications as needed
5. Teach patient to notify healthcare professionals
if antiemetics not successful in relieving
nausea
Peripheral Neuropathy
1. Assess sensory/motor changes prior to each
treatment
2. Notify prescriber/physician of alterations in
neurologic function
3. Discuss need for dose modifications
4. Teach patient about potential for neuropathy and
need to notify healthcare providers for difficulty in
performing ADLs
Wilkes G, Barton-Burke M. Oncology Nursing Drug Handbook (2011 Ed). Sudbury, MA: Jones and Bartlett Publishers, 2011.
Management of Side Effects of Agents
Used in the Management of NHL
Stomatitis
1. Perform oral assessment prior
to each treatment
2. Teach patient to perform good
oral hygiene and use
mouthwash with salt water or
salt and soda mouthwash
3. Recommend patient have dental
exam prior to starting treatment
4. Teach patient to contact health
professional for any mouth
discomfort
Wilkes G, Barton-Burke M. Oncology Nursing Drug Handbook (2011 Ed). Sudbury, MA: Jones and Bartlett Publishers, 2011.
Management of NHL in the Elderly
• Over half of new cases occur in those over
the age of 60 years
• Prognosis poor in the elderly
– Poor performance status
– Reduced vital organ reserve
– Comorbid diseases
– Biologic features of lymphoma
Management of NHL in Pregnancy
•
•
•
•
•
•
•
Lymphoma during pregnancy is rare (about 100 reported cases)
Therapy is based on histologic type and the point of gestation at diagnosis
Most women who develop NHL during pregnancy have aggressive histologies
and advanced-stage disease
Unusually high incidence of breast, ovarian, uterine and cervix involvement most likely due to hormonal influenced and increased blood flow to these
organs
Placental involvement rare
Transmission to fetus uncommon
Staging studies are limited due to concerns about radiation exposure during
pregnancy
–
–
–
–
•
CXR can be done
MRI can be used but to be avoided during first trimester
Ultrasound and echocardiograms can be useful
PET can be performed after delivery but since FDG is concentrated in breast
tissue, patients should avoid breast feeding for 72 hours after the scan
Prognosis for mother relatively poor:
– EFS 40-45%
– Due to aggressive nature of disease and advanced stage
Brenner B, et al. Lancet. 2012;379:580-587.
Management of NHL During
Pregnancy
• Abortion should be considered when aggressive lymphoma is
diagnosed during first trimester unless localized above diaphragm
– In that situation, can use involved field radiation therapy (with abdominal
shielding)
• Radiation should be avoided until third trimester
• Combination chemotherapy can be given in second or third trimester
– Anthracyclines have been given without untoward effects to mother or
fetus but should be avoided if possible
– Rituximab plus chemotherapy has been given without evidence of harm
• Early delivery should be considered:
– Avoid myelosuppression
– To initiate intensive chemotherapy
• Complete staging after delivery
• Low-grade lymphomas can be observed until after delivery
Brenner B, et al. Lancet. 2012;379:580-587.
Long-term Effect of Therapy
• Not as well defined as in HL
• Appear to be similar to HL and depend on:
– Therapy used
– Age of patient
– Comorbid illnesses
• Long-term effect:
– Endocrine - infertility, hypothyroid, panhypopituitarism, growth
retardation
– Psychosocial issues
– Transfusion - induced viral infections
– Second neoplasms
• Radiation is main cause of endocrine and neurologic toxicities and
secondary solitary neoplasms
• Cardiotoxicity from anthracyclines is manifested as CHF
– Cumulative incidence of cardiovascular disease in NHL treated with
anthracycline was:
• 12% at 5 years
• 22% at 10 years
Secondary Malignancies
• Increased risk over time for:
–
–
–
–
–
–
AML
Bladder cancer
Kidney cancer
Lung cancer
Malignant melanoma
HL
• Up to 10% of patients with NHL treated with
chemotherapy or autologous transplant may
develop MDS or AML within 10 years of their
initial therapy
Greer J, Williams M. Wintrobe’s Clinical Hematology (12th Ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009.
Key Takeaways
• NHL is a heterogeneous group of malignancies
that have distinct morphologic and molecular
differences
• The distinct subtypes of NHL require specific
management
• There are multiple prognostic indexes that can be
used to calculate the level of risk of the patient’s
lymphoma
• The prognosis is poorer in the elderly diagnosed
with NHL than in younger patients
• Nursing interventions can assist patients in
managing side effects from their treatment